1. Dr.Enamur Rahim Chowdhury 1

2. ERAS : ERAS : Enhanced Recovery After Surgery(CS) Guidelines for Perioperative Care in Cardiac Surgery : ERAS Cardiac Society Enhanced Recovery After Surgery(ERAS)Society Recommendations: Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. Enhanced Recovery After Surgery (ERAS) is a multimodal, transdisciplinary care improvement initiative to promote recovery of patients undergoing surgery throughout their entire perioperative journey. These programs aim to reduce complications and promote an earlier return to normal activities. The ERAS protocols have been associated with a reduction in overall complications and length of stay of up to 50% compared with conventional perioperative patient management in populations having non-cardiac surgery. 2

3.  Evidence-based ERAS protocols have been published across multiple surgical specialties.  In early studies, the ERAS approach showed promise in cardiac surgery (CS); however, evidence-based protocols have yet to emerge.  This article reports the first expert-consensus review of evidence-based CS ERAS practices.  Reference : JAMA Surgery August 2019 Volume 154, Number 8 755 https://jamanetwork.com jamasurgery.com © 2019 American Medical Association. All rights reserved.  They are organized into preoperative, intraoperative, and postoperative strategies. 3

4. Classification of Recommendation and Level of Evidence LOE by COR Recommendation I A Tranexamic acid or epsilon aminocaproic acid during on-pump cardiac surgical procedures B-R Perioperative glycemic control B-R A care bundle of evidence-based best practices to reduce surgical site infections B-R Goal-directed fluid therapy B-NR A perioperative, multimodal, opioid-sparing, pain management plan B-NR Avoidance of persistent hypothermia (<36.0°C) after cardiopulmonary bypass in the early postoperative period. B-NR Maintenance of chest tube patency to prevent retained blood B-NR Postoperative systematic delirium screening tool use at least once per nursing shift C-LD Stopping smoking and hazardous alcohol consumption 4 weeks before elective surgery 4

5. Classification of Recommendation and Level of Evidence LOE by COR Recommendation IIa B-R Early detection of kidney stress and interventions to avoid acute kidney injury after surgery B-R Use of rigid sternal fixation to potentially improve or accelerate sternal healing and reduce mediastinal wound complications B-NR Prehabilitation for patients undergoing elective surgery with multiple comorbidities or significant deconditioning B-NR An insulin infusion to treat hyperglycemia in all patients postoperatively B-NR Strategies to ensure extubation within 6 h of surgery C-LD Patient engagement tools, including online/application-based systems to promote education, compliance, and patient-reported outcomes C-LD Chemical or mechanical thromboprophylaxis after surgery C-LD Preoperative measurement of hemoglobin A1c to assist with risk stratification C-LD Preoperative correction of nutritional deficiency when feasible 5

6. Classification of Recommendation and Level of Evidence LOE by COR Recommendation IIb C-LD Continued consumption of clear liquids up until 2 to 4 h before general anesthesia C-LD Preoperative oral carbohydrate loading may be considered before surgery III (No Benefit) A Stripping or breaking the sterile field of chest tubes to remove clots. III (Harm) B-R Hyperthermia (>37.9°C) while rewarming on cardiopulmonary bypass. Abbreviations: A, A-level evidence; B-R, B-level evidence, randomized studies; B-NR, B-level evidence, nonrandomized studies; C-LD, C-level evidence, limited data; COR, classification of recommendation; LOE, level of evidence. 6

7. Preoperative Strategies : Preoperative Measurement of Hemoglobin A1c for Risk Stratification Optimal preoperative glycemic control, defined by a hemoglobin A1c level less than 6.5%, has been associated with significant decreases in deep sternal wound infection, ischemic events, and other complications. Evidence-based guidelines based on poor quality meta-analyses recommend screening all patients for diabetes preoperatively and intervening to improve glycemic control to achieve a hemoglobin A1c level less than 7% in patients for whom this is relevant. Preoperative Measurement of Albumin for Risk Stratification Low preoperative serum albumin in patients undergoing CS is associated with an increased risk of morbidity and mortality postoperatively (independent of body mass index). Hypoalbuminemia is a prognosticator of preoperative risk, correlating with increased length of time on a ventilator, acute kidney injury (AKI), infection, longer length of stay, and mortality. 7

8. Preoperative Correction of Nutritional Deficiency For patients who are malnourished, oral nutritional supplementation has the greatest effect if started 7 to 10 days preoperatively and has been associated with a reduction in the prevalence of infectious complications in colorectal patients. In patients undergoing CS who had a serum albumin level less than 3.0 g/dL (to convert to g/L, multiply by 10.0), supplementation with 7 to 10 days’ worth of intensive nutrition therapy may improve outcomes. Consumption of Clear Liquids Before General Anesthesia Several randomized clinical trials have demonstrated, however, that nonalcoholic clear fluids can be safely given up to 2 hours before the induction of anesthesia, and a light meal can be given up to 6 hours before elective procedures requiring general anesthesia. Encouraging clear liquids until 2 to 4 hours preoperatively is an important component of all ERAS protocols outside of CS. A small study in patients undergoing CS demonstrated that an oral carbohydrate drink consumed 2 hours preoperatively was safe, and no incidents of aspiration occurred. Aspiration pneumonitis has not been reported, although this potential remains in patients undergoing CS who have delayed gastric emptying owing to diabetes mellitus, and transesophageal echocardiography(TEE) may also increase aspiration risk. 8

9. Preoperative Carbohydrate Loading A carbohydrate drink (a 12-ounce clear beverage or a 24-g complex carbohydrate beverage) 2 hours preoperatively reduces insulin resistance and tissue glycosylation, improves postoperative glucose control, and enhances return of gut function. In patients undergoing CS, preoperative carbohydrate administration was found to be safe and improved cardiac function immediately after cardiopulmonary bypass. Patient Engagement Tools Patient education and counseling prior to surgery can be completed in person, through printed material, or through novel online or application- based approaches. These efforts include explanations of procedures and goals that may help reduce perioperative fear, fatigue, and discomfort and enhance recovery and early discharge. 9

10. Prehabilitation A cardiac prehabilitation program should include education, nutritional optimization, exercise training, social support, and anxiety reduction, although current existing evidence is limited. Prehabilitation enables patients to withstand the stress of surgery by augmenting functional capacity. Preoperative exercise decreases sympathetic over reactivity, improves insulin sensitivity, and increases the ratio of lean body mass to body fat. It also improves physical and psychological readiness for surgery, reduces postoperative complications and the length of stay, and improves the transition from the hospital to the community. Smoking and Hazardous Alcohol Consumption Screening for hazardous alcohol use and cigarette smoking should be performed preoperatively. Tobacco smoking and hazardous alcohol consumption are risk factors for postoperative complications and present another opportunity for preoperative interventions. They are associated with respiratory, wound, bleeding, metabolic, and infectious complications. Smoking cessation and alcohol abstinence for 1 month are associated with improved postoperative outcomes after surgery 10

11. Surgical Site Infection Bundle, Including Classification of Recommendation and Level of Evidence LOE by COR Recommendation I A Perform topical intranasal decolonization prior to surgery A Administer intravenous cephalosporin prophylactic antibiotic 30-60 min prior to surgery C Clipping (as opposed to shaving) immediately prior to surgery IIb C Use a chlorhexidine-alcohol–based solution for skin preparation before surgery IIa C Remove operative wound dressing after 48 h Abbreviations: COR, classification of recommendation; LOE, level of evidence 11

12. Intraoperative Strategies : Surgical Site Infection Reduction To help reduce surgical site infections, CS programs should include a care bundle that includes topical intranasal therapies, depilation protocols, and appropriate timing and stewardship of perioperative prophylactic antibiotics, combined with smoking cessation, adequate glycemic control, and promotion of postoperative normothermia during recovery. Evidence supports topical intranasal therapies to eradicate staphylococcal colonization in patients undergoing CS. 18% to 30% of all patients undergoing surgery are carriers of Staphylococcus aureus, and they have 3 times the risk of S. aureus surgical site infections and bacteremia. It is recommended that topical therapy be applied universally. Two studies validate the reduction of such infections in patients receiving mupirocin. 12

13. Cont. of Surgical Site Infection Reduction Weight-based cephalosporins should be administered fewer than 60 minutes before the skin incision and continued for 48 hours after completion of CS. When the surgery is more than 4 hours, antibiotics require redosing. A meta-analysis of skin preparation and depilation protocols indicates that clipping is preferred to shaving. Clipping using electric clippers should occur close to the time of surgery. Postoperative measures including sterile dressing removal within 48 hours and daily incision washing with chlorhexidine are potentially beneficial. 13

14. Hyperthermia Moderate-quality prospective studies have demonstrated that when rewarming on cardiopulmonary bypass (CPB), hyperthermia (core temperature >37.9°C) is associated with cognitive deficits, infection, and renal dysfunction. Any postoperative hyperthermia within 24 hours after coronary artery bypass grafting has been associated with cognitive dysfunction at 4 to 6 weeks. Rewarming on CPB to normothermia should be combined with continuous surface warming. Thus, we recommend avoiding hyperthermia while rewarming on cardiopulmonary bypass. 14

15. Rigid Sternal Fixation Most cardiac surgeons use wire cerclage for sternotomy closure. This achieves approximation and compression, but does not eliminate side-by-side movement, and thus rigid fixation is not achieved with wire cerclage. In 2 multicenter randomized clinical trials, sternotomy closure with rigid plate fixation resulted in significantly better sternal healing, fewer sternal complications, and no additional cost, compared with wire cerclage at 6 months after surgery. Patient-reported outcome measures demonstrated significantly less pain, better upper-extremity function, and improved quality-of-life scores, with no difference in total 90-day cost. Additional research demonstrated decreased mediastinitis, painful sternal nonunion relief after median sternotomy, and superior bony healing. Based on these studies, the consensus concluded that rigid sternal fixation has benefits in patients undergoing sternotomy and should be especially considered in individuals at high risk, such as those with a high body mass index, previous chest wall radiation, severe chronic obstructive pulmonary disorder(COPD), or steroid use. 15

16. Tranexamic Acid or Epsilon Aminocaproic Acid In a large randomized clinical trial of patients undergoing coronary revascularization, total blood products transfused, and major hemorrhage or tamponade requiring reoperation were reduced using tranexamic acid. Higher dosages, however, appear to be associated with seizures. A maximum total dose of 100 mg/kg is recommended. Based on this evidence, tranexamic acid or epsilon aminocaproic acid is recommended during on-pump cardiac surgical procedures. 16

17. Postoperative Strategies : Perioperative Glycemic Control Interventions to improve glycemic control are known to improve outcomes. Preoperative carbohydrate loading has resulted in reduced glucose levels after abdominal surgery and CS. After CS, hyperglycemia morbidity is multifactorial and attributed to glucose toxicity, increased oxidative stress, prothrombotic effects, and inflammation. Insulin Infusion Treatment of hyperglycemia (glucose >160-180mg/dL [to convert to mmol/L, multiply by 0.0555]), with an insulin infusion for the patient undergoing CS, may be associated with improved perioperative glycemic control. Postoperative hypoglycemia should be avoided, especially in patients with a tight blood glucose target range (ie, 80-110 mg/dL). Randomized clinical trials support insulin infusion protocols to treat hyperglycemia perioperatively. 17

18. Pain Management Opioids are associated with multiple adverse effects, including sedation, respiratory depression, nausea, vomiting, and ileus. There is growing evidence that multimodal opioid-sparing approaches can adequately address pain through the additive or synergistic effects of different types of analgesics, permitting lower opioid doses in the population receiving CS. Nonsteroidal anti-inflammatory drugs are associated with renal dysfunction after CS. Selective COX-2 inhibition is associated with a significant risk of thromboembolic events after CS. The safest nonopioid analgesic may be acetaminophen (Paracetamol) Intravenous acetaminophen may be better absorbed until gut function has recovered postoperatively. Acetaminophen produces superior analgesia, an opioid-sparing effect, and independent antiemetic actions. Acetaminophen dosing is 1 g every 8 hours 18

19. Cont. of Pain Management # 2 Tramadol has dual opioid and nonopioid effects but with a high delirium risk. Pregabalin also decreases opioid consumption and is used in postoperative multimodal analgesia. Pregabalin given 1 hour before surgery and for 2 postoperative days improves pain scores compared with placebo. A 600-mg gabapentin dose, 2 hours before CS, lowers pain scores, opioid requirements, and postoperative nausea and vomiting. Dexmedetomidine, an intravenous α-2 agonist, reduces opioid reuirements. A medium-quality meta-analysis of dexmedetomidine infusion reduced all-cause mortality at 30 days with a lower incidence of postoperative delirium and shorter intubation times. Dexmedetomidine may reduce AKI after CS. Ketamine has potential uses in CS owing to its favorable hemodynamic profile, minimal respiratory depression, analgesic properties, and reduced delirium incidence. 19

20. Cont. of Pain Management # 3 Patients should receive preoperative counseling to establish appropriate expectations of perioperative analgesia targets. Pain assessments must be made in the intubated patient to ensure the lowest effective opioid dose. The Critical Care Pain Observation Tool, Behavioral Pain Scale, and Bispectral Index monitoring may have a role in this setting. There is sufficient evidence to recommend that CS programs use acetaminophen, Tramadol, dexmedetomidine, and pregabalin (or gabapentin) based on formulary availability. 20

21. Postoperative Systematic Delirium Screening Delirium is an acute confusional state characterized by fluctuating mental status, inattention, and either disorganized thinking, or altered level of consciousness that occurs in approximately 50% of patients after CS. Delirium is associated with reduced inhospital and long-term survival, freedom from hospital readmission, and cognitive and functional recovery. Early delirium detection is essential to determine the underlying cause (ie, pain, hypoxemia, low cardiac output, and sepsis) and initiate appropriate treatment. 21

22. Postoperative Systematic Delirium Screening # 2 A systematic delirium screening tool such as the Confusion Assessment Method for the Intensive Care Unit or the Intensive Care Unit Delirium Screening Checklist should be used. The perioperative team should consider routine delirium monitoring at least once per nursing shift. There is no evidence that prophylactic antipsychotic use (eg, haloperidol) reduces delirium. Owing to the complexity of delirium pathogenesis, it is unlikely that a single intervention or pharmacologic agent will reduce the incidence of delirium after CS. 22

23. Persistent Hypothermia Postoperative hypothermia is the failure to return to or maintain normothermia (>36°C) 2 to 5 hours after an intensive care unit (ICU) admission associated with CS. Hypothermia is associated with increased bleeding, infection, a prolonged hospital stay, and death. Large registry observational studies suggest if hypothermia is of short duration, outcomes can be improved. Based on this evidence, we recommend prevention of hypothermia by using Forced air warming blankets, raising the ambient room temperature, and warming irrigation and intravenous fluids to avoid hypothermia in the early postoperative period. 23

24. Chest Tube Patency A pericardial drain is always necessary after CS to evacuate shed mediastinal blood. Drains used to evacuate shed mediastinal blood are prone to clogging with clotted blood in up to 36% of patients. When these tubes clog, shed mediastinal blood can pool around the heart or lungs, necessitating reinterventions for tamponade or hemothorax. Retained shed mediastinal blood hemolyzes and promotes an oxidative inflammatory process that may further cause pleural and pericardial effusions and trigger postoperative atrial fibrillation. 24

25. Chest Tube Patency # 2 Chest tube manipulation strategies that are commonly used in an attempt to maintain tube patency after CS are of questionable efficacy and safety. One example is chest-tube stripping or milking, in which the practitioner strips the tubes toward the drainage canister to break up visible clots or create short periods of high negative pressure to remove clots. In meta-analyses of randomized clinical trials, chest-tube stripping has been shown to be ineffective and potentially harmful. Another technique used to maintain patency is to break the sterile field to access the inside of chest tubes and use a smaller tube to suction the clot out. This technique may be dangerous, because it can increase infection risk and potentially damage internal structures. 25

26. Chest Tube Patency # 3 To address the unmet need to prevent chest-tube clogging, active chest-tube clearance methods can be used to prevent occlusion without breaking the sterile field. This has been demonstrated to reduce the subsequent need for interventions to treat retained blood compared with conventional chest tube drainage in 5 nonrandomized clinical trials of CS. Active chest-tube clearance has also been shown to reduce postoperative atrial fibrillation, suggesting that retained blood may be a trigger for this common problem. While there are no standard criteria for the timing of mediastinal drain removal, evidence suggests that they can be safely removed as soon as the drainage becomes macroscopically serous. Based on these clinical trials, maintenance of chest tube patency without breaking the sterile field is recommended to prevent retained blood complications. Stripping or breaking the sterile field of chest tubes to remove clot is not recommended. 26

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28. Chemical Thromboprophylaxis Vascular thrombotic events include both deep venous thrombosis and pulmonary embolism, represent potentially preventable complications after CS. Patients remain hypercoagulable after CS, increasing vascular thrombotic event risk. All patients benefit from mechanical thromboprophylaxis achieved with compression stockings and/or intermittent pneumatic compression during hospitalization, or until they are adequately mobile to reduce the incidence of deep-vein thrombosis after surgery even in the absence of pharmacological treatment. Prophylactic anticoagulation for vascular thrombotic events should be considered on the first postoperative day and daily thereafter. A recent medium-quality meta analysis suggested that chemical prophylaxis could reduce vascular thrombotic event risk without increasing bleeding or cardiac tamponade. Based on this evidence, pharmacological prophylaxis should be used as soon as satisfactory hemostasis has been achieved (most commonly on postoperative day 1 through discharge). 28

29. Extubation Strategies : Prolonged mechanical ventilation after CS is associated with longer hospitalization, higher morbidity, mortality, and increased costs. Prolonged intubation is associated with both ventilator associated pneumonia and significant dysphagia. Early extubation, within 6 hours of ICU arrival, can be achieved with time directed extubation protocols and low-dose opioid anesthesia. This is safe (even in patients at high risk) and associated with decreased ICU time, length of stay, and costs. A meta-analysis demonstrated that ICU times and length of stay were reduced; however, no difference in morbidity and mortality occurred, likely because of disparate study design and statistical under powering. Thus, studies have shown early extubation to be safe, but efficacy in reducing complications has not been conclusively demonstrated. Based on this evidence, we recommend strategies to ensure extubation within 6 hours of surgery. 29

30. Kidney Stress and Acute Kidney Injury : Acute kidney injury (AKI) complicates 22% to 36% of cardiac surgical procedures, doubling total hospital costs. Strategies to reduce AKI involve assessing which patients are at risk and then implementing therapies to reduce the incidence. Urinary biomarkers (such as tissue inhibitor of metalloproteinases-2, and insulin like growth factor-binding protein 7) can identify patients as early as 1 hour after CPB who are at increased risk of developing AKI. In a randomized clinical trial after CS, patients with positive urinary biomarkers who were assigned to an intervention algorithm had reductions in subsequent AKI. The algorithm included avoiding nephrotoxic agents, discontinuing angiotensin-converting enzyme inhibitors and angiotensin II antagonists for 48 hours, close monitoring of creatinine and urine output, avoiding hyperglycemia and radio contrast agents, and close monitoring to optimize volume status and hemodynamic parameters. All patients undergoing CS may benefit from detection of modifiable early kidney stress to prevent AKI. 30

31. Goal-Directed Fluid Therapy : Goal-directed fluid therapy uses monitoring techniques to guide clinicians with administering fluids, vasopressors, and inotropes to avoid hypotension and low cardiac output. While many clinicians do this informally, goal-directed fluid therapy uses a standardized algorithm for all patients to improve outcomes. Quantified goals include blood pressure( MAP-Perfusion pressure),CVP,SVV(Stroke volume variation), cardiac index(C.I), SVR, systemic venous oxygen saturation( ScVO2,SVO2), and urine output. Additionally, oxygen consumption, oxygen debt, and lactate levels may augment therapeutic tactics. Goal-directed fluid therapy trials consistently demonstrate reduced complication rates and length of stay in surgery overall and specifically in CS. Based on this, we recommend goal-directed fluid therapy to reduce postoperative complications. 31

32. Other Important, Ungraded ERAS Elements : Preoperative anemia is common and associated with poor outcomes in patients undergoing noncardiac surgery. Patients scheduled for CS may have multifactorial causative mechanisms for anemia, including acute or chronic blood loss, vitamin B12, or folate deficiency, and anemia of chronic disease. If time permits, all causes of anemia should be investigated, but data supporting improved outcomes in the literature on CS is weak. Intraoperative anesthetic and perfusion considerations are also important ERAS elements. Impaired renal oxygenation has been demonstrated during CPB and is ameliorated by an increase in CPB flow. This may contribute to postoperative renal dysfunction and suggests that goal directed perfusion strategies need to be considered. Other anesthetic considerations may include a comprehensive protective lung ventilation strategy. Multiple studies have established that clinicians should use a low tidal volume strategy for mechanical ventilation in CS. Early postoperative enteral feeding and mobilization after surgery are other essential components of ERAS surgical protocols. 32

33. Conclusions : In CS, a fast-track project to improve outcomes was first initiated by bundling perioperative treatments. The ERAS pathway was initiated in the 1990s by a group of academic surgeons to improve perioperative care for patients receiving colorectal care, but it is now practiced in most fields of surgery. Although ERAS is relatively new to CS, we anticipate that programs can benefit from these recommendations as they develop protocols to decrease unnecessary variation and improve quality, safety, and value for their patients. Cardiac surgery involves a large clinician group working in concert throughout all phases of care. Patient and caregiver education and system wide engagement (facilitated by specialty champions and nurse coordinators) are necessary to implement best practices. A successful introduction of ERAS protocols is possible, but a broad-based, multidisciplinary approach is imperative for success. 33

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